Keys To Diagnosing And Treating Lisfranc Injuries

In the event of misdiagnosis or delayed diagnosis, Lisfranc injuries can lead to compromised vascular supply or persistent instability. Accordingly, these authors offer diagnostic insights, discuss conservative care options, review the conflicting literature on analgesic management and explore the benefits of open reduction and internal fixation.

Tarsometatarsal injuries are relatively common, constituting approximately 0.2 percent of all fractures and occurring in one person per 55,000 annually.^1-4 Most commonly affecting males, the injury frequently arises during the third decade of life.⁵ Physicians misdiagnose or miss up to 20 percent of Lisfranc fracture dislocations during the initial evaluation.⁶ An accurate diagnosis is a prerequisite for appropriate management in order to avoid long-term consequences and functional impairment.⁷ A delayed diagnosis compromises vascular supply. A missed diagnosis can lead to persistent instability, deformity or arthritis, which necessitates a post-traumatic reevaluation 10 days later after the inciting event.⁸

The term “Lisfranc dislocation” characterizes fracture-dislocation of the tarsometatarsal joint complex.^1,7,9 The Lisfranc complex consists of bony and ligamentous elements, that contribute to providing structural support to the transverse arch.⁹ The oblique interosseous ligament is the strongest structure supporting the tarsometatarsal joint.⁷

However, fracture-dislocation injuries can be osseous, ligamentous or a combination of both involving the middle of the foot. These midfoot injuries result from direct trauma (bending or twisting movements applied to the midfoot) or indirect trauma (crush injuries with soft tissue trauma), and high velocity (motor vehicle accidents) or low velocity (fall) impacts.⁹ Twisting injuries occur during athletic trauma but can occur when stumbling. According to Myerson and colleagues, 67 percent of all tarsometatarsal joint injuries are the result of motor vehicle accidents whereas crushing injuries and falls from heights account for most of the rest.^3,4 Vuori and Aro reported that up to one-third of Lisfranc injuries result from low-energy trauma.⁶ The most common mechanisms of trauma for non-diabetic patients include high velocity (58 percent) indirect mechanisms (42 percent) that cause axial loading or rotation on a plantarflexed foot.¹⁰

How To Classify Ligamentous Injuries
The American Medical Association’s classification defines first- and second-degree ligamentous sprains as partial tears, and defines a third-degree sprain as a complete rupture of the ligamentous support.^3,11

Quenu and Kuss classified ligamentous injuries into three categories based on the direction of the displaced metatarsal: homolateral (category A), isolated (category B) and divergent (category C).¹²
Hardcastle and coworkers noted the prognosis of tarsometatarsal joint injuries depended more on articular incongruity than the mechanism of injury.¹³ Type A injuries indicate complete displacement of all metatarsals or complete incongruity of the tarsometatarsal joint complex. Type B reflects partial incongruity and Type C is a divergent pattern.

Myerson and colleagues modified the system based on the direction of the dislocation.^3,4 The authors divided Type B injuries into medial (B1) and lateral (B2) dislocations. The classification systems help with treatment planning since the metatarsals within a column work as a functional unit.

Potential Complications With Mistreated Lisfranc Injuries
Many authors have concluded that there is an increased chance of degenerative changes if the presence or extent of injury has initially gone unrecognized, if the injury had only partial treatment, if the anatomy was not restored, or if the injury was ligamentous and not osseoligamentous.^6,9 When one misdiagnoses Lisfranc injury as a sprain or renders insufficient treatment, complications such as osteoarthritis and midfoot pain result. The outcome of Lisfranc injuries depends on the severity of injury to the cartilaginous joint surface with the most common outcome being midfoot arthritis.⁹

Komenda and colleagues demonstrated that symptomatic posttraumatic arthritis is most common at the base of the second metatarsal.¹⁴ These injuries cause significant pain and swelling in the midfoot, resulting in decreased weightbearing. Plantar ecchymosis is pathognomonic for joint complex injuries.⁷ Severe injuries distort the foot and cause pain on weightbearing. The instability and the potential for posttraumatic arthritis are greater with tarsometatarsal as well as intertarsal injury.⁹ The treatment of these injuries differs from that of the more commonly isolated middle column subluxation.⁹

Without proper diagnosis and treatment, these fractures ultimately lead to painful malunion and impaired functions of the injured region. Clinical symptoms include soft tissue swelling, increased warmth and weightbearing of the base of the first and second metatarsals. Computed tomography (CT) or magnetic resonance imaging (MRI) can reveal occult fractures and dislocations.

A Brief Primer on Midfoot Anatomy
A thorough understanding of midfoot anatomy is required to assess the extent of injury and treatment options. The anatomic overview consists of the forefoot, which contains the metatarsals and phalanges; the midfoot, which consists of the cuneiform, navicular and cuboid bones; and the hindfoot, which consists of the talus and calcaneus.² The Lisfranc joint separates the forefoot from the midfoot.

The tarsometatarsal complex consists of three functional columns.¹⁴ The medial column is formed by the base of the first metatarsal and medial cuneiform; the middle column is formed by the second and third metatarsals and respective cuneiforms; and the lateral column is formed by the fourth and fifth metatarsals and cuboid.¹⁵ Within the transverse arch, from the first through third metatarsals and articulations with cuneiform bones, the second metatarsal forms articulations with five other metatarsal bones.¹⁴

Displacement between the second and middle cuneiform occur with displacement of the third through fifth metatarsals.³ An inherent weakness exists due to the lack of ligaments between the first and second metatarsals, and the weaker dorsal transverse ligaments.¹⁵ Most dislocations occur in a dorsal and lateral direction. Significant dislocation does not occur unless the second metatarsal base area is disrupted.⁴

Essential Diagnostic Insights
As the tarsometatarsal joint complex spans the width of the foot, several muscular and ligamentous injuries may occur, causing tenderness to palpation, limited range of motion and decreased strength. Pain occurs when testing plantarflexion, dorsiflexion and divergent movement of the first and second metatarsals.¹ As described by Wiley and coworkers, significant pain can occur during pronation-abduction testing with a fixed hindfoot.⁸ Pain occurs with the forefoot abducted and pronated. The authors deemed that manipulation of the midfoot with passive pronation and simultaneous abduction is sensitive in allowing determination of instability patterns, and distinguishing third-degree sprains from stable first- and second-degree sprains.^7,8

The diagnostic tarsometatarsal squeeze test or compression test elicits pain along the medial and lateral midfoot.¹⁶ The squeeze test compresses the lower leg at the mid-calf in order to separate the distal tibia and fibula, stress the syndesmosis and elicit pain proximal to the ankle joint.

Neurovascular compression testing can aid in identifying acute compartment syndrome.¹⁶ By assessing the dorsalis pedis pulse, one can identify compromised blood flow from a dislocated second metatarsal. Acute compartment syndrome is a significant finding when pain and swelling are prominent. This requires orthopedic consultation.

In this particular case with the concern of compartment syndrome, it is important to utilize diagnostic imaging and assess the significance of injuries using the Ottawa ankle rule.^15,17 Medical imaging is necessary if any of the following are present: point tenderness over the base of the fifth metatarsal; point tenderness over the navicular bone; and inability to take four steps, both immediately after injury and in the emergency department.^15,17 One should also pursue imaging if there is pain in the malleolar zone with tenderness over the posterior edge or the tip of the lateral or medial malleolus. The Ottawa ankle rule is essential in evaluating pathologic fractures in children over 5 years of age through adulthood.¹⁷

In one study, authors compared the Ottawa ankle rule to subjective orthopedic surgeon assessment of foot and ankle fractures after sprains.¹⁸ The researchers found that the Ottawa ankle rule had a 97.2 percent sensitivity in comparison to a 55.6 percent sensitivity for an orthopedic surgical consultation. One should keep in mind that the Ottawa ankle rule had a low specificity (7.8 percent) in comparison to the 90.1 percent specificity for the orthopedic surgeon consult. Accordingly, positive findings with the Ottawa ankle rule can lead to misdiagnosis of a fracture. However, given the high sensitivity of the Ottawa ankle rule, the study authors found it to be a reliable determination for using radiographs in patients with foot or ankle sprains. They also found the inability to bear weight on the injured extremity to be an important factor in predicting the presence of fractures.

When there is pain in the midfoot zone and bone tenderness over areas of potential fracture, one can utilize diagnostic imaging with lateral anterior-posterior (AP) and oblique plain radiographs to confirm the nature of midfoot injuries.^14,15 The AP films demonstrate dislocations along the collinear aspect of the medial border of second metatarsal and associational dislocations with medial border of the intermediate cuneiform.¹⁵ Oblique films show the medial border of the fourth metatarsal with the medial border of the cuboid.^17,19

Pathologic diagnosis reveals malalignment greater than 2 mm.^1,19 The AP or oblique view demonstrates avulsion fracture at the base or insertion of the Lisfranc ligament including the base of the second metatarsal and medial cuneiform.¹⁹ Radiographic imaging demonstrates diastasis of the base of the first and second metatarsals. A “fleck sign” is also pathognomonic in 90 percent of cases, illustrating a small avulsion fragment from either the lateral edge of the medial cuneiform or the medial aspect of the second metatarsal base with the presence of proximal metatarsal fracture.²⁰ Lateral views demonstrate a malalignment with the border of cuboid and cuneiform bones.

Confirmatory analyses require CT scans or MRI. Computed tomography helps delineate fracture patterns, identify subtle malalignment and identify intra-articular bone fragments and soft tissues interposed in fracture fragments.¹⁷ The value of CT examination allows for optimal evaluation of midfoot malalignment with the oblique axial plane to visualize the length of the Lisfranc ligament. However, MRI has a higher sensitivity and specificity for detecting Lisfranc injuries as well as demonstrating stability along the Lisfranc complex and the need for surgical referral.⁵

A Guide To Initial Conservative Management Of Acute Lisfranc Injuries
Acute management of the joint complex requires immobilization with a short leg splint or boot, and advising the patient to avoid bearing weight on the injured extremity.⁹ Other common conservative modalities include applying ice to reduce swelling and inflammation; use of a compression dressing with an elastic wrap; and elevation of the injured foot above the level of the heart to reduce fluid accumulation.

In a randomized trial, the Aircast Air-Stirrup brace had significantly higher Karlsson scores for ankle joint function at 10 days and one month than an elastic bandage in the treatment of lateral ligament ankle sprains.²¹ In another randomized trial involving 172 patients with lateral ligamental sprains, the combination of an Aircast Air-Stirrup brace and elastic compression wrap improved overall joint function during 10-day and one-month follow-ups.²² The researchers concluded that an Air-Stirrup brace along with an elastic compression wrap or lace-up support brace was better than monotherapy with elastic compression.²²

Authors have also noted that a below-knee cast cannot provide beneficial long-term improvements in the management of ankle sprains.²¹ Early mobilization allows the patient to tolerate weightbearing for daily activities in comparison to prolonged rest in the management of acute, severe ankle sprains.²² The combination of focused range of motion exercises within the first week with functional mobilization provides benefits for patients to return to normal activities sooner than expected.

What The Literature Reveals About Analgesic Management
Analgesics such as acetaminophen and other non-steroidal anti-inflammatory drugs (NSAIDs) are effective for pain control. Severe pain requires treatment with opiates but one should exercise caution with dosing of these medications when there is impaired renal clearance in older populations. Conventional NSAIDs and newer cyclooxygenase-2 (COX-2) inhibitors are in common use in musculoskeletal trauma and orthopedic surgery to reduce inflammatory response and pain.

However, there have been mixed findings in the literature about the use of these medications. Dimmen and colleagues found that parecoxib and indomethacin had a negative impact on tendon healing in rats.²³ Ferry and coworkers emphasized judicious use of anti-inflammatory drugs, including selective and nonselective cyclooxygenase inhibitors, in the acute period after injury or surgical repair at the bone-tendon junction.²⁴

Researchers have reported a small increased risk of non-union from the use of NSAIDs and COX-2 agents in patients with bone fractures.^25-27 Preclinical and clinical studies have suggested a possible role for cyclooxygenases in bone repair as well as concerns about the use of NSAIDs in patients with various skeletal injuries. Zhang and coworkers demonstrated that COX-2 played an essential role in both endochondral and intramembranous bone formation during skeletal repair.²⁸ However, they also noted a delay in tibia fracture stabilization with increased fibrous non-union due to a histology that revealed undifferentiated mesenchymal cells and marked reduction in osteoblastogenesis.

Similarly, Simon and colleagues described the role of COX-2 in rats and its role in fracture healing and pro-inflammatory prostaglandin production.²⁷ The authors demonstrated that COX-2 selective NSAIDs halted production of pro-inflammatory prostaglandin but also found that normal fracture healing was altered. This showed that COX-2 activity was necessary for normal fracture healing and the effects of COX-2 selective inhibitors alter endochondral ossification.

Bhattacharyya and coworkers demonstrated the relationship between nonunion of humeral shaft fractures and NSAIDs in older adults.²⁶ After studying 9,995 patients with humeral shaft fractures, 1.1 percent developed non-union and 10.3 percent of the study patients were exposed to NSAIDs within 90 days after fracture. The authors found that exposure to NSAIDs or opiates at 61 to 90 days after fracture was also associated with non-union.

In a meta-analysis of 11 cohort and case-control studies, Dodwell and colleagues found the pooled odds ratio for non-union with NSAID exposure was 3.0.²⁵ In addition, authors found no statistically significant association between NSAID exposure and non-union in seven spine fusion studies. There was a significant association between lower quality studies and a higher reported odds ratio. They advocated randomized controlled trials to confirm or refute findings from their meta-analysis of observational studies. Despite the risks, physicians often outweigh the benefits of both NSAIDs and COX-2 inhibitors in patients with significant tarsometatarsal injuries.

A Closer Look At Open Reduction And Internal Fixation Of Lisfranc Injuries
When conservative measures fail or there is significant soft tissue injury or bone injury, surgery consists of open reduction and internal fixation (ORIF). This procedure can also be successful after six weeks in a patient with delayed diagnosis.⁶ Authors have previously advocated surgical repair as an option for treatment of severe injuries. Surgery has provided significant benefits for chronic pain, functional instability and pain that is unresponsive to rehabilitation, and also allows a return to pre-injury status for sports participation.²⁹

Open reduction using parallel incisions in the dorsum of the foot and small fragment screws is our preferred method of choice to address injury to the first and second metatarsal joints.³ Additionally, one may employ K-wires to help stabilize the lateral column of the midfoot and subsequently remove them during postoperative follow-up. However, when surgeons use Kirschner wires alone, they have a limited role in the treatment of midfoot injuries.^3,4 Surgeons often bury K-wires subcutaneously to decrease the risk of infection but they are easy to insert and easy to pull out.³ The advantage of screw fixation allows for rigid reduction with gentle compression across the joint. Screw fixation also provides more stability to the medial and middle columns.

In a randomized prospective study, Ly and Coetzee compared ORIF with primary arthrodesis in patients with ligamentous injury.³⁰ Patients undergoing primary arthrodesis had a quicker recovery and superior return to function than those who had ORIF. In contrast, Henny and coworkers determined that there was no difference in the functional results in groups treated with ORIF versus arthrodesis.³¹ Therefore, additional studies are required to clarify a definitive plan of recommended treatment and proper management.

Addressing The Post-Op Protocol
During the postoperative period, one should address several issues, including limitations on weightbearing, resumption of activities and the removal of internal fixation. One can permit partial protected weightbearing in a walking boot after incisions heal.⁷

Patients with significant sprains and fractures should have examination four to six weeks after the injury to assess symptoms of ligament instability.²⁹ For example, the anterior drawer test assesses the integrity of the anterior talofibular ligament, which demonstrates significant anterior subluxation. The talar tilt test stresses the calcaneofibular ligament, which demonstrates laxity.

Postoperatively, we recommend placing the patient in a non-weightbearing splint to protect the bones and incisions.⁹ Elevating the foot reduces pain and swelling. In addition, adequate medication will control the pain. Advise the patient to return to the clinic two weeks after surgery for suture removal.³ Placing the patient in a cast or boot allows him or her to sustain immobility for four to six weeks. Progressive weightbearing begins at post-op week six and ends eight to 10 weeks after the surgery, depending on the symptoms.^3,4 Remove pins six to eight weeks after surgery and have the patient use a rigid shoe support to stabilize the midfoot 10 to 12 weeks after surgery.³ One should maintain internal fixation for a minimum of four months for ligament healing.⁷ Dislocations, in comparison to fractures, take longer to heal and require more time for joint stability.⁷

Patients are required to perform physical activity during rehabilitation.³ Supervised physical therapy ensures appropriate intensity levels and correct exercises. Stretching exercises also help the patient regain full midfoot function. For athletic patients, there is a recommendation to wait at least four to six months postoperatively prior to returning to normal activity.³

There is substantial evidence to support rehabilitation exercises to reduce future ankle injuries as well as other lower limb injuries in athletes.^32-34 Athletes returning after an injury should participate in a neuromuscular training program. In order to reduce the risk of lower limb injury, we suggest sport specific warm-ups prior to intense exercise.³³ Static stretching has no effect for injury prevention.³⁴

In Conclusion
Injuries of the tarsometatarsal complex require a high index of suspicion when one is evaluating a patient with midfoot pain or multiple traumas.^3,4 Clinicians should not overlook Lisfranc injuries in patients with multiple traumas and cases in which there is spontaneous reduction of the diastasis.

The physical examination of patients with Lisfranc injuries reveals edema, tender forefoot and plantar ecchymosis.⁷ A thorough neurovascular examination rules out compartment syndrome secondary to direct and crush injury.¹⁰

One should obtain standard radiographs including three views of the foot. However, subtle injuries may require bilateral weightbearing films. X-rays may show broken and/or shifted bones in the middle of the foot.¹ In addition, a confirmatory diagnosis with CT or MRI can determine the extent of ligamentous damage, malalignment and injury.⁴

However, there is a lack of consensus in the literature regarding conservative care and pain management, surgical treatment, complications and functional outcomes of Lisfranc injuries.⁷ Nonetheless, one should take into consideration the initial articular cartilaginous damage that occurs at the time of injury. The risk of developing degenerative changes markedly increases if the presence or extent of injury is misdiagnosed or unrecognized, and the anatomy is not restored.³ Post-traumatic arthritis in the midfoot joints can lead to severe pain and stiffness due to degeneration of cartilage.⁴

Unrecognized and untreated injuries can cause an increase in pressure within the muscles that can damage the nerves and blood vessels. If there is early diagnosis, clinicians can address most Lisfranc dislocation injuries with conservative management and anti-inflammatory medications to remedy symptoms. However, there have been various controversies about the use of anti-inflammatories and exacerbated symptoms. This suggests the need for more research to determine the appropriate measures of conservative management with pain medication and limiting adverse effects that could lead to ligamentous damage.

If the standard treatment for a sprain as well as pain management fails to reduce the pain and swelling, or if there is extensive bruising of the bottom of the foot, surgical intervention is required.⁷ Surgical treatment allows for realignment of the joints and returns the bone fragments to normal position.³⁵

Dr. Shah is an MD graduate of the class of 2016 from the American University of Antigua.

Dr. DeMeo is the Director of Foot and Ankle Surgery at Interfaith Medical Center in Brooklyn, NY.

References

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18.     Pires R, Pereira A, Abreu-E-Silva G, et al. Ottawa ankle rules and subjective surgeon perception to evaluate radiograph necessity following foot and ankle sprain. Ann Med Health Sci Res. 2014; 4(3):432-5.
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Additional References

   36. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med. 2001;35(2):103-108.
   37. Owen RJ, Hickey FG, Finlay DB. A study of metatarsal fractures in children. Injury. 1995;26(8):537-8.
   38. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;(3):CD003762.
   39. Van Rijn RM, van Ochten J, Luijsterburg PA, van Middlekoop M, Koes BW, Bierma-Zeinstra SM. Effectiveness of additional supervised exercises compared with conventional treatment alone in patients with acute lateral ankle sprains: systematic review. Br Med J. 2010;341:c5688.
   40. Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010;18(12):718-728.
   41. Thordarson DB, Hurvitz G. PLA screw fixation of Lisfranc injuries. Foot Ankle Int. 2002;23(11):1003-1007.
   42. Arntz CT, Veith RG, Hansen ST Jr. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70(2):173-181.

For further reading, see “A Novel Approach To Treating Lisfranc Fractures” in the January 2011 issue or the DPM Blog “What You Should Know About The ‘Lisfranc Fracture Equivalent’” at https://tinyurl.com/z54jfb5.

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